Wrist arthroscopy in children and adolescents: a single surgeon experience of thirty-four cases

Arthroscopic Capsular Shrinkage Is Safe and Effective in the Treatment of Midcarpal Instability in a Pediatric Population: A Single-Center Experience of 51 Cases

Objective  Treatment of palmar midcarpal instability (PMCI) remains controversial and children can develop PMCI from asymptomatic hypermobility. Recently, case series have been published regarding the use of arthroscopic thermal shrinkage of the capsule in adults. Reports of the use of the technique in children and adolescents are rare, and there are no published case series. Methods  In a tertiary hand center for children's hand and wrist conditions, 51 patients were treated with arthroscopy for PMCI between 2014 and 2021. Eighteen out of 51 patients carried additional diagnosis of juvenile idiopathic arthritis (JIA) or a congenital arthritis. Data were collected including range of movement, visual analog scale (VAS) at rest and with load, and grip strength. Data were used to determine the safety and efficacy of this treatment in pediatric and adolescent patients. Results  Mean follow-up was 11.9 months. The procedure was well tolerated and no complications were recorded. Range of movement was preserved postoperatively. In all groups VAS scores at rest and with load improved. Those who underwent arthroscopic capsular shrinkage (ACS) had significantly greater improvement in VAS with load, compared with those who underwent arthroscopic synovectomy alone ( p  = 0.04). Comparing those treated with underlying JIA versus those without, there was no difference in postoperative range of movement, but there was significantly greater improvement for the non-JIA group in terms of both VAS at rest ( p  = 0.02) and VAS with load ( p  = 0.02). Those with JIA and hypermobility stabilized postoperatively, and those with JIA with signs of early carpal collapse and no hypermobility achieved improved range of movement, in terms of flexion ( p  = 0.02), extension ( p  = 0.03), and radial deviation ( p  = 0.01). Conclusion  ACS is a well-tolerated, safe, and effective procedure for PMCI in children and adolescents. It improves pain and instability at rest and with load, and offers benefit over open synovectomy alone. This is the first case series describing the usefulness of the procedure in children and adolescents, and demonstrates effective use of the technique in experienced hands in a specialist center. Level of Evidence  This is a Level IV study.

Adolescent Wrist Pain

Adolescence is a difficult time, both physically and emotionally. Rapid growth coupled with physical changes in the background of high levels of activity can be overwhelming. Meanwhile, unfamiliar life stressors coupled with undeveloped compensatory mechanisms can lead to overwhelming anxiety and emotional distress. Emotional factors can make injuries and overuse syndromes feel more catastrophic. Occasionally, an adolescent's emotional distress can manifest physically, without antecedent injury or physiologic cause. Understanding the psychological milieu is as important as understanding the disease processes that can affect adolescents if one hopes to manage these patients effectively.

Role of Wrist Arthroscopy in Juvenile Inflammatory Arthritis

Background and Purposes  The wrist is the fourth most common joint to be involved in juvenile inflammatory arthritis (JIA), which is a common rheumatological condition affecting children. Wrist arthroscopy is well established in rheumatoid arthritis, but remains unexplored in JIA. The aim of this study is to investigate the role of wrist arthroscopy in JIA, with focus on those who are refractory to medical management. Methods  This is a prospective observational study, including consecutive patients with JIA undergoing arthroscopy between January 2016 and December 2020. Those over the age of 18 years and those with other rheumatological diagnoses were excluded. Data including pre-, intra-, and postoperative variables, demographics, and patient-reported outcomes were collated and are reported using standard measures. Results  A total of 15 patients underwent arthroscopy ( n  = 20 wrists). Synovitis was noted in all wrists on arthroscopy and synovectomy was performed in all cases. Other procedures were performed as indicated during the procedure. The median follow-up duration was 11.3 (interquartile range [IQR] 8.1-24.2) months. Median reduction of 4 (IQR 2.25-6) points on the Visual Analogue Score for pain on loading was noted postoperatively. Grip strength was improved in n  = 11/20 wrists and functional improvement was noted in n  = 18/20 wrists. Restriction of range of motion was achieved with a shrinkage procedure in patients with hypermobile joints. There were no postoperative complications, and no patients were lost to follow-up. Conclusion  In experienced hands, wrist arthroscopy is feasible, safe, and efficacious in the management of JIA, among patients who are refractory to medical management. Level of Evidence  This is a Level II study.

Wrist Arthroscopy Is Effective for the Diagnosis and Treatment of Chronic Wrist Pain in Pediatric Patients

Purpose

To determine the outcomes of diagnostic and therapeutic arthroscopy in patients with chronic wrist pain who are younger than 16 years of age.

Methods

We retrospectively analyzed collected data from medical records of patients who had undergone wrist arthroscopy by the senior author between 2015 and 2017 for longstanding wrist pain and were 16 years old or younger. Findings from preoperative magnetic resonance imaging (MRI) were compared with the intraoperative diagnosis, and midterm results were gathered by a telephone interview.

Results

Ten patients were included. Eight of 10 patients had undergone conservative therapy before surgery, and 60% had a history of single trauma. In 6 of 10 patients, the arthroscopic diagnosis correlated with the MRI findings. Eight of 10 wrists (80%) showed a tear of the triangular fibrocartilage complex (TFCC). Only 4 of the 8 TFCC tears were correctly identified by 3-Tesla MRI.

Conclusions

In our study, wrist arthroscopy was an effective tool not only to diagnose but also to treat relevant TFCC lesions both in adolescents and children suffering from persistent wrist pain. A 3-Tesla MRI was neither sensitive nor specific enough to correctly diagnose lesions in small pediatric wrists.

Level of Evidence

IV, Therapeutic case series.

Triangular Fibrocartilage Complex Injuries in Children and Adolescents

Triangular fibrocartilage complex (TFCC) tears can cause ulnar-sided wrist pain in children and adolescents following acute rotational injury or prior distal radius fracture. Surgical treatment, guided by the Palmer classification, is considered after activity modification and occupational therapy. All concomitant wrist pathologies, such as distal radioulnar joint instability, ulnocarpal impaction, and distal radius malunion, must be recognized and addressed at the time of TFCC debridement or repair. This article reviews recent literature guiding clinical evaluation and surgical treatment of children and adolescents with TFCC injuries. The authors' techniques for arthroscopic-assisted outside-in repair of Palmer 1B and 1D tears are described.

Arthroscopic Treatment Results of Triangular Fibrocartilage Complex Tears in Adolescents: A Systematic Review

INTRODUCTION

Injury to the triangular fibrocartilage complex (TFCC) may cause chronic wrist pain and instability if left untreated. The current literature of adult cases suggests that arthroscopic treatment offers favorable outcomes and is associated with a low complication rate. This systematic review evaluated the outcomes of arthroscopic TFCC surgery in adolescents.

MATERIALS AND METHODS

A PRISMA-guided literature search of PubMed, Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Cochrane Clinical Answers was conducted in May 2020. All studies reporting on (1) arthroscopic TFCC repair or debridement in (2) patients under the age of 19 years with (3) a minimum case number of four patients were extracted by two independent observers. The level of evidence of each study was assessed according to the Oxford Centre for Evidence-Based Medicine, and study quality was graded according to the Modified Coleman Methodology Score and the MINORS criteria. Clinical outcome scores, functional parameters, and any complications were reviewed.

RESULTS

The selected search terms initially resulted in a total of 986 possible articles. The authors eventually identified eight papers (all LoE IV) for inclusion in this systematic review. A total of 254 patients with verified TFCC tears and a mean age of 16 years (range, 7-19) received arthroscopic repair (162 patients, 67.1% of total) or debridement (77 patients, 29.7% of total). Arthroscopic treatment resulted in low pain levels, high patient satisfaction, and a fast return to sport. Complications overall were sparse and consisted mainly of persistent wrist pain (n = 31) and temporary paresthesia (n = 6) of the dorsal sensory branch of the ulnar nerve. Recurrent tears were sparse, with only four reported cases due to sports participation.

CONCLUSION

Wrist arthroscopy is a reliable surgical option for treating TFCC tears in adolescents. The results obtained are comparable to those published in the literature. However, the variety of repair techniques and the low level of evidence across all included articles demand further prospective studies.

Severe Pediatric Wrist Joint Sequelae following Blunt Trauma in the Presence of Chronic Regional Pain Syndrome

Introduction The pediatric chronic regional pain syndrome (CRPS) type I is a recognized syndrome that follows a preliminary event (e.g., trauma, fracture) with amplified spontaneous or stimuli-induced extremity pain that differs from its adult form with rather favorable outcomes. Conservative treatment is usually indicated for CRPS treatment. Case Description We present a unique case of an adolescent girl who revealed severe wrist joint sequelae following a blunt trauma, complicated by a challenging CRPS resistant to treatment. Diagnostic wrist arthroscopy eventually revealed a massive cartilage degeneration and scapholunate tear as underlying causes for the pain and CRPS. It was decided to proceed with radioscapholunate wrist fusion, which promptly led to pain relief and disappearance of the CRPS. Conclusion The relevance of this report is therefore to emphasize the possibility, against earlier thoughts, that well-indicated surgeries in pediatric CRPS patients may lead to prompt symptom improvement and may not be uniformly predicted to fail. With the clinical probability of a presence of an uncontrolled, symptomatic causative factor such as cartilage degeneration and chondrolysis, further early diagnostic and therapeutic interventions may be indicated to control the disease.

Early Results of Surgical Treatment of Triangular Fibrocartilage Complex Tears in Children and Adolescents

PURPOSE

To investigate the clinical results and patient-reported outcomes following surgical treatment for triangular fibrocartilage complex (TFCC) tears in the pediatric and adolescent population.

METHODS

We reviewed 149 patients with 153 arthroscopy-confirmed TFCC tears. Mean age at surgery was 15.5 years (range, 7-19 years). There were 86 females. Plain radiographs and magnetic resonance imaging were used to characterize bony and soft tissue pathology. Mayo Modified Wrist Score (MMWS) and Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity Short Form assessed functional outcomes. Median patient follow-up was 21.8 months (IQR:5.9-55.4).

RESULTS

Pre-operatively, all patients had wrist pain or instability with activities. The median pre-operative MMWS was 80 (interquartile range [IQR], 65-90). Fifty-six (35%) presented with positive ulnar variance. Concomitant pathology included distal radioulnar joint (DRUJ) instability (14%), ulnocarpal impaction (20%), ulnar styloid nonunion (33%), and distal radius growth arrest (30%). On arthroscopy, there were 15 (10%) isolated 1A, 79 (52%) 1B, 1 (1%) 1C, 30 (20%) 1D tears, and 25 (16%) cases of multiple tears. Twenty-six percent of wrists underwent TFCC debridement, 68% arthroscopy-assisted repair, 6% both for combined tears. Fifty-one percent of wrists underwent bony procedures-most commonly ulnar-shortening osteotomy to achieve neutral ulnar variance (40%) and symptomatic ulnar styloid nonunion excision with concomitant TFCC repair (39%). At final follow-up, pain, wrist range of motion, DRUJ stability, ulnar variance, and MMWS (median, 95 [IQR, 86.5-100]) improved significantly. The median PROMIS T-score at final follow-up was 57 (IQR, 45-57). The MMWS was better in those with concomitant bony procedures at index surgery than those with only repair or debridement of TFCC tears.

CONCLUSIONS

Most pediatric TFCC tears are posttraumatic and peripheral. Surgical treatment of TFCC tears and concomitant pathology in the pediatric and adolescent population results in decreased pain, improved motion and stability, and excellent functional outcomes in the majority of patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Wrist Arthroscopy in Athletes

Arthroscopy is a surgical technique whose indication for wrist injuries has grown in recent years. Athletes are subject to traumatic injury to the wrist due to training overload or the intensity of the activity during competition. The need of a quick return to sports practice makes arthroscopy a very useful minimally invasive technique in these situations. The authors present indications of sports-related injuries to the wrist that can be treated by arthroscopy. A literature review is also presented.

Arthroscopic treatment of triangular fibrocartilage complex injuries in paediatric and adolescent patients

We assessed outcomes of 43 paediatric and adolescent patients (44 wrists) undergoing arthroscopic triangular fibrocartilage complex surgery by a single surgeon between 2003 and 2016. Medical records were reviewed for clinical, imaging, and operative data. Preoperatively, 49% of patients had additional diagnoses and mean QuickDASH was 47. Patients were telephoned to assess current wrist pain, subsequent treatment(s), satisfaction, and to complete QuickDASH and Patient-Rated Wrist Evaluation questionnaires. Twenty-five patients responded with mean follow-up of 70 months (minimum 13 months). In those patients not reached by telephone, mean clinical follow-up was 21 months. Seven patients had subsequent surgery (most commonly ulnar shortening osteotomy); this was associated with lower satisfaction scores. At final follow-up, mean QuickDASH was 4, Patient-Rated Wrist Evaluation 8 and patient and parent satisfaction scores were 9 and 9 out of 10, respectively. In conclusion, arthroscopic triangular fibrocartilage complex treatment in paediatric patients yielded favourable outcomes and patient/parent satisfaction. Level of evidence: IV.

TFCC Lesions in Children and Adolescents: Open Treatment

BACKGROUND

There has been little discussion regarding the lesion of the TFCC in pediatric and adolescent patients. This study examines 11 cases treated with open technique.

METHODS

Range of motion (ROM), strength and functional scores (QUICK DASH, PWRE, VAS pain, and NAKAMURA score) were evaluated.

RESULTS

The mean postoperative flexion-extension arc was 95% of the contralateral side, the radio-ulnar deviation 91% of the contralateral side and the pronation-supination arc 94% of the unaffected side. Grip strength was 85.6% of the uninjured wrist, pinch was 88%. The mean PRWE decreased from 84.4 to 9.85 postoperatively. The mean Q-DASH scored 10.4. The VAS pain under stress decreased from a mean of 6.8 to a mean of 2.27, while at rest it decreased from a mean of 5 to a mean of 0.5. The final clinical results obtained by Nakamura score were 2 excellent, 6 good and 3 fair.

CONCLUSIONS

This study emphasizes that open surgical TFCC repair is a safe and reliable therapeutic procedure in children and adolescent populations.

Outcomes of Operative Treatment of Triangular Fibrocartilage Tears in Pediatric and Adolescent Athletes

BACKGROUND

Triangular fibrocartilage complex (TFCC) tears have been treated with increasing frequency in pediatric and adolescent patients over the past decade. There is little information on these injuries in young athletes and a scarcity of data regarding their ability to return to preinjury levels of athletic participation. The purpose of this study was to review the outcomes of pediatric and adolescent athletes with operatively treated TFCC tears with or without a concurrent ulnar shortening osteotomy and to determine their ability to return to their preoperative level of activity.

METHODS

A retrospective chart review was performed for all patients who underwent operative treatment of TFCC tears between 2006 and 2012 within one Upper Extremity practice. Patients were included if they were high-level athletes, unable to participate in their sport secondary to wrist pain and desired to return to their sport. All operative patients had imaging studies and clinical findings consistent with TFCC injury as the primary source of their activity-limiting pain and had failed nonoperative management prior to surgery. Patients without at least 3 months of documented postoperative follow up were excluded.

RESULTS

In total, 22 patients were included in the chart review with 20 patients willing to participate in a telephone survey and PODCI. Eighty percent of patients returned to their sport following operative treatment of their injury at an average of 4.8 months. Seven of the 22 patients underwent a concurrent ulnar shortening osteotomy for ulnar positive variance. All 20 patients reported satisfaction with the outcomes of their surgery and treatment.

CONCLUSIONS

Operative treatment of TFCC injuries in adolescent and pediatric athletes after failure of conservative treatment allowed return to sport at the previous level of participation. Concurrent ulnar shortening osteotomy in the setting of ulnar positive variance did not prohibit return to high-level athletic participation.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Ganglionectomy in the Pediatric Population

BACKGROUND

Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population.

METHODS

All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics.

RESULTS

There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again.

CONCLUSION

Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Wrist Arthroscopy in Juvenile Idiopathic Arthritis: A Review of Current Literature and Future Implications

Introduction  Juvenile Idiopathic Arthritis (JIA) is the most common rheumatological condition in children and frequently affects the wrist. The roles for wrist arthroscopy and arthroscopic synovectomy (AS) in JIA are unclear. Our aim was to find the current evidence supporting its use. Methods  Systematic literature review of relevant publications from 1990 to present in the Cochrane Library, Clinical Knowledge Summaries, DynaMed, PEMSoft, NICE Guidance, MEDLINE, EMBASE, and PubMed. Results  We found no publications detailing the use of arthroscopy or AS specifically in patients with JIA involving the wrist. There is evidence that AS reduces pain, improves function, and induces remission in patients with rheumatoid arthritis resistant to medical management. Discussion and Conclusion  Although there is paucity in evidence for the use of AS in the wrists of patients with JIA, studies suggest it to be safe and effective, and could be applied to patients with refractive JIA. It is possible that early identification of patients suffering from JIA with extensive joint destruction and little symptoms could benefit from AS, delaying joint destruction and preserving function.

Outcomes after Arthroscopic Debridement of the Triangular Fibrocartilage Complex in Adolescents

Background  To the best of our knowledge, we are not aware of any reports focusing on results of arthroscopic debridement of triangular fibrocartilage complex (TFCC) tears in immature patients. Purpose  The purpose of this study was to evaluate our results after arthroscopic debridement of TFCC tears in adolescents. Materials and Methods  We retrospectively identified all patients of 18 years or less, who received an arthroscopic TFCC debridement due to a traumatic or degenerative tear according to Palmer. These cases were clinically re-evaluated after a mean period of 6.7 years (SD ± 3.9 years). All patients completed the Modified Mayo Wrist Score (MMWS), Disabilities of the Arm, Shoulder and Hand (DASH) inventory, and Patient-Rated Wrist Evaluation (PRWE). Results  Thirteen adolescent patients (mean age: 15.6 ± 2.2 years at surgery) were included. The mean MMWS increased significantly from 70 ± 13.6 to 90 ± 6.5 after the TFCC debridement; mean postoperative DASH and PRWE scores of 17 ± 15.2 and 21 ± 18.5, respectively, indicated good and excellent outcomes for the majority of the cohort. The mean pain level decreased significantly from a mean of 5.7 ± 2.0 to 1.8 ± 2.0 at follow-up. Six patients needed a reoperation to achieve a successful outcome. Conclusion  Arthroscopic debridement of TFCC tears, performed as a concomitant wrist surgery in adolescents, efficiently reduced wrist pain and yielded good to excellent results in the long term. However, under certain circumstances, its results are unpredictable and further surgery may be necessary to eventually achieve the satisfying outcomes. Further studies are needed to confirm these findings. Level of Evidence  Level IV, therapeutic case series.

Wrist Arthroscopy in Children and Adolescent With Chronic Wrist Pain: Arthroscopic Findings Compared With MRI

BACKGROUND

Wrist arthroscopy is a dynamic diagnostic procedure and its indications are growing as a treatment modality in the adult population. The aim of the study was to retrospectively report our series of pediatric and adolescence with chronic wrist pain, with or without wrist instability who underwent wrist arthroscopy after failing at least 4 months of conservative management. Our secondary aim was to report the sensitivity and specificity of clinical examination and magnetic resonance imaging evaluation for various injury subgroups against the gold standard of the arthroscopic findings. Technical challenges, complications, and outcomes are also discussed.

METHODS

A retrospective review of the medical records of 32 pediatric and adolescent patients who underwent wrist arthroscopy was conducted. Preoperative clinical diagnosis, radiographic, and intraoperative findings including classifications of triangular fibrocartilage complex (TFCC) and interosseous ligaments were obtained. Patients were followed up to 1 year postoperatively and were discharged if symptom free.

RESULTS

Thirty-three wrist arthroscopies in 32 patients were performed from 1996 to 2004. There were 2 male and 30 female patients. At arthroscopy 16 wrists were found to have TFCC injuries, 11 wrists had scapholunate injuries, and 8 had lunotriquetral (LT) injuries. Clinical examination for diagnosis of TFCC injury was too sensitive and nonspecific; however, clinical diagnosis of scapholunate injury was sensitive and specific. LT injury was under diagnosed clinically. Magnetic resonance imaging was found to have a low sensitivity for diagnosis of LT injury but diagnosis of TFCC was sensitive and specific.

CONCLUSIONS

The sex ratio of 2 males:30 females was startling. Nevertheless, this therapeutic level 3 study supports a thorough search for pathology in any patient with persistent wrist symptoms because pathology was identified in 32 of the 33 wrists at arthroscopy.

LEVEL OF EVIDENCE

Level III-Therapeutic.

Efficacy of Magnetic Resonance Imaging and Clinical Tests in Diagnostics of Wrist Ligament Injuries: A Systematic Review

PURPOSE

To investigate the diagnostic performance of magnetic resonance imaging (MRI) and clinical provocative tests on injuries to the triangular fibrocartilage complex (TFCC), the scapholunate (SL) ligament, and the lunotriquetral (LT) ligament.

METHODS

An electronic literature search of articles published between January 1, 2000, and February 28, 2014, in PubMed, Embase, and the Cochrane Library was carried out in April 2014. Only studies of the diagnostic performance of MRI and clinical provocation tests using wrist arthroscopy as the gold standard were eligible for inclusion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist guided the extraction and reporting of data. The methodologic quality of the included articles was assessed with the revised Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The primary outcome measure was the negative predictive value (NPV) of wrist MRI and provocative wrist tests, which was defined as the probability of an intact wrist ligament given a negative investigation. The question was whether negative results of MRI or provocative tests were enough to safely discontinue further investigation with arthroscopy. A minimum NPV of 95% was considered a clinically relevant cutoff value. The secondary outcome measures were the positive predictive value (PPV), sensitivity, and specificity.

RESULTS

A total of 7 articles (327 patients with MRI and 105 patients with clinical tests) were included in this systematic review. The included articles displayed heterogeneity regarding participants, diagnostic methods, and study design. Seven articles investigated the diagnostic performance of MRI, whereas 1 article investigated clinical testing. The NPVs of MRI were as follows: TFCC, 37% to 90%; SL ligament, 72% to 94%; and LT ligament, 74% to 95%. The NPVs of clinical tests were 55%, 74%, and 94% for the TFCC, SL ligament, and LT ligament, respectively. Only 1 study reached the predetermined cutoff value for the primary outcome measure (NPV ≥95%) but only for MRI of the LT ligament; this study also reached a borderline-cutoff NPV of 94% for MRI of the SL ligament. Another study reached borderline-cutoff NPVs of 94% both for MRI and for clinical tests of the LT ligament.

CONCLUSIONS

A negative result from MRI is unable to rule out the possibility of a clinically relevant injury to the TFCC, SL ligament, or LT ligament of the wrist. Clinical provocation wrist tests were of limited diagnostic value. The current gold standard--wrist arthroscopy--remains the preferred diagnostic technique with sufficient conclusive properties when it comes to wrist ligament injuries.

LEVEL OF EVIDENCE

Level II, systematic review of Level II diagnostic studies.

Distal radio-ulnar joint instability in children and adolescents after wrist trauma

This study retrospectively evaluated the medical records and radiographs of patients younger than aged 25 that were referred for a second opinion due to ulnar-sided wrist pain and persistent distal radio-ulnar (DRU) joint instability. We identified 85 patients with a major wrist trauma before the age of 18. Median age at trauma was 14 years. Median time between trauma and diagnosis of DRUJ instability was 3 years. Sixty-seven patients (79%) had sustained a fracture at the initial trauma. The two most common skeletal injuries related to the DRUJ instability were Salter-Harris type II fractures (24%) and distal radius fractures (19%). In 19 patients (22%), the secondary DRUJ instability was caused by malunion or growth arrest. Eighteen patients (21%) had no fracture; in spite of this, they presented with subsequent symptomatic DRUJ instability. Fourteen of these 18 patients had a triangular fibrocartilage complex (TFCC) tear, confirmed by arthroscopy, open surgery, or magnetic resonance imaging. In conclusion, late DRUJ instability due to wrist fractures or isolated TFCC tears was found to be common in children and adolescents.

LEVEL OF EVIDENCE

IV.

Pathomorphologic findings of wrist arthroscopy in children and adolescents with chronic wrist pain

PURPOSE

The purposes of this diagnostic study were to show pathomorphologic findings of children and adolescents with persistent wrist pain and to compare these arthroscopic findings with preoperative magnetic resonance imaging (MRI).

METHODS

A total of 41 arthroscopies in 39 patients were retrospectively reviewed. The patients underwent diagnostic wrist arthroscopy because of persistent wrist pain after at least 3 months of unsuccessful conservative treatment. Of the patients, 22 (56.4%) reported an injury before the onset of pain. The mean age at arthroscopy was 15.3 years (range, 9.8 to 19.4 years), and the mean duration between the onset of symptoms and arthroscopic exploration was 19.9 months (range, 3.0 to 121.0 months).

RESULTS

Among all affected wrists, 33 (80.5%) showed a triangular fibrocartilage complex (TFCC) tear on arthroscopy, with 75.6% also showing other pathomorphologic findings. Retrospectively, the condition of the TFCC was correctly identified by MRI in only 17 wrists (41.5%). In contrast, 23 wrists were incorrectly classified as having "no tear" whereas arthroscopy later indeed showed a TFCC tear. Concerning the TFCC, MRI and arthroscopy showed a significant difference of outcome (P < .01), indicating low agreement (κ = 0.09) for the outcome of the 2 methods. A larger proportion of TFCC tears was found for patients with injuries (91.3%) as compared with the other patients (66.7%), although this was not significant on statistical analysis (P = .11). No significant difference in the time to surgery was found between patients with TFCC tears and those without TFCC tears classified by MRI (P = .76) and by arthroscopy (P = .99).

CONCLUSIONS

Wrist arthroscopy in children and adolescents with chronic wrist pain shows TFCC lesions in a high percentage. However, most of these lesions have not been correctly identified by MRI before arthroscopy. Thus diagnostic wrist arthroscopy may be recommended to rule out underlying pathologies and initiate further therapeutic steps.

LEVEL OF EVIDENCE

Level III, diagnostic study of nonconsecutive patients.